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Please print or type, (Form designed for use on elite <br />�UMFORM HAZARDOUS I• GeneratorlD Numl <br />. WASTE MANIFEST CA I W1 <br />*47^I,,;r11% <br />me <br />ALLEY WASTE OIL <br />RECEIVI�0 <br />'ypeWror.) ? Form A prc <br />2. P i pf 3. qr0 Response Phone 4. Manifest Tracking Number <br />r r F <br />209-067.8667 �address) <br />73 <br />t than mallinr <br />4ME DEPARTMENT,, � �{ -io I 4 u <br />I L(,o , <br />U.S. EPA ID Number <br />ER U.S. EPA ID Number <br />:4:af31r XAl-JIS RkI A0 <br />RIVERBANK, silt► 9530'7 rt".,lko l)o l <br />Faciiitv's Phone: t <br />OMB No. 2050-0039 <br />5 FLE <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total. <br />HM <br />and Packing Group (if any)) <br />Quantity <br />12. Unit <br />WLNoI. <br />13. Waste Codes <br />No. <br />Type <br />1 <br />i <br />.. <br />221 <br />_ <br />11SF Ri n'�11..5i° ., <br />2. <br />+i . <br />1 <br />i <br />3. <br />4. <br />s <br />14. Special HandlinWjtT)"Jd Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulations. If export shipment and 1 am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. <br />GenKators/Offames PdnMa vnPrl h1AmA <br />--t 16. International Shipments <br />F' ❑ import to U.S. <br />z <br />Transporter signature {(or exports only): <br />W 17, Transporter Acknowledgment of Receipt of Materials <br />❑ Export from U.S. Pod of entrylextt <br />Date leavina U.S. <br />Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue <br />18b. Alternate Facility (or Generator) Manifest Refer9nce Nur <br />U <br />d <br />�- Facili % Phare: <br />18c. Signature of Alternate Facility (or Generator) <br />y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W f. <br />�.I7e L. I F 2. <br />.. 3. <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as no ed M Item 18a <br />Printedi7yped Name Sgr1 4e <br />EPA Form 870042 (Rau 05) Previous editions are obsolete. _ <br />❑ Partial Rejection <br />U.S, EPA ID Numbe! <br />4. <br />rv,uuui u y rear <br />❑ Full Rejection <br />DESIGNATED FACILITY TO GENERATOR <br />